Heart Failure Disease Specific Certification –The Joint

Institute for Healthcare Improvement Reducing Avoidable Readmissions Seminar

3/26/2013

1

REDUCING

READMISSIONS

St. Luke’s Hospital Case Study

Cedar Rapids, IA

Reducing Readmission Seminar

April 2014

San Diego

ST. LUKE’S HOSPITAL

MEMBER, UNITYPOINT HEALTH

Private hospital – Cedar Rapids, Iowa

Affiliate in the UnityPoint Health

system

Licensed for 500 Beds with more than

17,000 admissions

Truven Top 100 Hospital – 5 years

(2013); Heart Hospital 3 years (2012)

Iowa Recognition for Performance

Excellence Gold Award - 2010

Magnet Designation – 2009, 2014

The Joint Commission Disease-

Specific Certification in Advanced

Heart Failure, Stroke, Palliative Care

and Total Joint. Society of Chest

Pain Center – Chest Pain

Certification

Gold Award from Get with Guidelines

for Heart Failure 2010-2013


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WHY IS REDUCING AVOIDABLE

REHOSPITALIZATIONS STRATEGIC FOR

ST. LUKE’S HOSPITAL?

It is part of our mission: “To give the healthcare

we’d like our loved ones to receive”

It represents goals that are aligned with

healthcare reform: providing better value for

decreased costs. Learning has been incorporated

into our present work with development of

population management and ACO work

TRANSITION TO HOME TEAM MEMBERS

CHAIR: Peg Bradke, VP-Post-Acute Care

Robinn Bardell, Mgr-Case Mgmt

Sarah Baumert, Mgr-5E

Diane Pfeiler, PCC-3C

Alexis Benion, Living Center West

Dean Bleadorn, Mgr-RT

Myrt Bowers, Assoc Exec Dir-Witwer Center

Shelley Cahalan, Gen Mgr-VNA

Christy Charkowski, STL Hospitalists

Sara Claeys, Dietary Svcs

Christina Djerf, Prog Coord-Lifeline

Elizabeth Eichhorn, ARNP-Living Center

West

Krissy Elder, PCC-5C

Karen Forster, Pharm

Terri Grantham, APN-Card Outcomes

Renee Grummer-Miller, OP Pall. Care

Barb Haeder, APN-Card Outcomes

Sue Halter, ARNP-STL HF Clinic

Signe Henderson, Coord-Home Care

Amrita Samra, MD, CRMEF

Sherrie Justice, Dir-PI

Carmen Kinrade, VP-Nursing Excellence

Patty Koelker, PCC-5E

Jennifer Mahoney, UPH Clinic - Northridge

Shirley McCloy, Resp Ther

Sandi McIntosh, Dir-ED

Jennifer Owens, Med Soc Svcs

Julie Peterson, Mgr-Card Rehab

Karen Pierce, Data Analyst, PI

Amrita Samra, MD - CRMEF

Brandi Simmons, Living Center West

Amy Schweer, STL HF Clinic

Marilinne Staub, UM Spec.

Aimee Traugh, Mgr-3C

Sheila Tumility, Reg PI Proj Mgr

Brook Van Dee, ARNP-OP Pall. Care

Jean Westerbeck, Living Center West

Pam Williams, JRMC Resp Care

Sharon Zimmerman, Resp Care

Dr. Todd Langager, Cardiology Medical

Director


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VOICE OF THE CUSTOMER

Feedback from Chronic Disease Management class

Patient and family members on our Patient-Family Advisory Council

Feedback from follow-up phone calls

Feedback from Cardiopulmonary Rehab participants

Feedback from High-Risk Clinic Patients

CROSS-CONTINUUM TEAM

Meets monthly

Reviews readmissions for each month related

to core diagnosis to assess causes and

opportunities for improvement

Reviews process and outcome measures

Continually testing and improving,

aggregating the experiences of patients,

families and caregivers

Each facility reports in testing occurring in

their area


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SEVERAL SUBGROUPS REPORT INTO THE

LARGER TRANSITION TO HOME TEAM

Data Management

Patient Education processes

Home Care

SNF/Nursing Facilities work processes

Physician Clinic processes

Case Management/Social Work/Care Coordination

Several members of the Transition to Home team are members of

the hospital ACO and Population Health Management work.

Information is bidirectional between these teams.

Continuum of Care Process

Standardized care through order sets.

Use of the clinical indicator sheet as a checklist for evidence-based care being met.

Report developed to identified key core measure patients – (e.g. BNP, Troponin etc)

Teaching:

• Utilizing Universal Health Literacy Concepts

• Enhanced teaching materials

• Teach back

Utilization of whiteboard to individualize patient’s plan of care and communicate to team.


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Continuum of Care (2)

Bedside report to involve patient and family caregivers as partners in care.

Daily huddles are facilitated with the patient care nurse, charge nurse, and care coordinator. Daily goals are reviewed providing opportunity to review plan for the day, available support for patient, discharge goals, and determine what it will take to get the patient home safely. Assessment of palliative care referral is part of discussion.

Standardized Disease specific on-line discharge instructions.

Continuum of Care (3)

Touch points post discharge:

Home Care - care coordination visit 24 to 48 hours post discharge on high risk patients

Physician Clinic follow up appointment made prior to discharge for 3-7 days after returning home

Follow-up phone call set up based on post discharge needs at 5-9 days

Standardized tool for transfer of information to nursing facilities for next level of care .

Telehealth monitor available through Home Care

Chronic Disease Management Program for patients

In addition staff participate in Integrated Chronic Disease Management class


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ENHANCED ADMISSION ASSESSMENT

During Admission Assessment, the patient and family are asked, “Who would you like to have present when we provide your discharge information?”

Information added to the whiteboard

RN and physician do medication reconciliation Concentrated effort for Admission. Dedicated Admission Center RN’s complete home medication list and prepare an appropriate list for physician to address. At times, the pharmacy or physician offices need to be called to get additional information. If the patient is a home care patient, the home care agency is called to get the current list of medications

ENHANCED ADMISSION ASSESSMENT (2)

Referral to Palliative Care for patient with advanced

stages of disease - the referrals have consistently

increased. Team rounds daily on units

Bedside report to involve the patient and family

caregivers as partners in their care. Daily discharge

huddle is facilitated daily with the RN caring for the

patient, the charge nurse, and unit-based case manager

Take 5 completed on patient at start of shift. Daily goals

are reviewed and written on the whiteboards in each

room, providing the opportunity to review the plan for

the day, anticipate discharge needs, and determine what

it will take to get the patient home safely


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Interview Questions

For patients that are readmitted within 30 days of last

admission:

Can you tell me in your own words why you think you

ended up sick enough to be readmitted again?

Can you tell me what a typical meal has been for you

since you left the hospital? What did you have for

dinner last night?

Have you seen your doctor since you were discharged

from the hospital?

Do you have all of your medications? How do you set

up your pills every day?

Were there any appointments that kept you from

taking any of your pills?

“The patient is noncompliant.”

vs.

Asking, “What is our responsibility as the

sender of the information?”

PARADIGM SHIFT


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ENHANCED TEACHING AND LEARNING

The patient education materials facilitate the use of

Teach Back, and the same materials are used across

the continuum: in the hospital, with home care,

long-term care settings and the clinic.

Short, succinct material developed for each Core

Measure DRG. Teach Back question part of packet

for staff and patient reference.

Patient teaching flowsheets set up to address Teach

Back and assure the documentation and use of

Teachback.


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TEACH BACK WITH DISCHARGE

INSTRUCTIONS

Can you show me on these instructions:

How you find your doctors’ office appointment?

What other tests you have scheduled and

when?

Is there anything on these instructions that could

be difficult for you to do?

Have we missed anything?

Who will you call if you have questions?

ENHANCE TEACHING AND

FACILITATE LEARNING

Use Teach Back:

In the hospital

During home visits and follow-up phone calls

To assess the patient’s and family caregiver’s understanding of

discharge instructions and ability to do self-care

Building Teach Back into our work

Session in Nursing Orientation

Session in Nursing Residency Program

Net Learning module, competency validation, and in-house

prepared instructional DVD with Teach Back demonstration

Closing staff meetings, walking the talk

Staffs participate in Chronic Disease Management


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HEART FAILURE MAGNET

LOW SODIUM EATING PLAN BROCHURE

Cover page Back page


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26


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Where To Start? Go to the Unresolved

Education Tab

Select the topic you

educated on

Begin charting on the

right side of the screen

What you taught on

Additional comments


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DISCHARGE ASSESSMENT - SMART TEXT

POST-ACUTE CARE FOLLOW-UP

Home Care Visit set up for 24-48 hours after

discharge. Home Care liaison in-house. Teach Back

questions part of visit .

Partnership with physicians’ offices resulted in

redesign of scheduling follow-7p visits to allow office

visits within seven days for patients.

Appointments are scheduled prior to discharge and

noted on discharge instructions.

Advanced Medical Team Pilot in Pulmonology Clinic

with High Risk/High Resource patients.

Consistent Care Plan Program in Emergency Dept.


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3W TEST OF CHANGE


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EMERGENCY DEPARTMENT CONSISTENT

CARE PLAN

Consistent Care Program (EDCCP) for patients who had visited the ED 12 or more times in the previous 12 months.

103 Care Plans were developed, mailed, and implemented.

Care Plans are a communication tool that provide data specific to that patient’s medical history and current medical needs, along with Goals of Care for when patients present in the Emergency Dept.

Using care plans and with intervention by a social work case manager, there has been a reduction in patient’s Emergency Department use.


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CONSISTENT CARE PROGRAM

REAL-TIME HANDOVER COMMUNICATIONS

Medication Reconciliation is a joint physician and nurse

accountability.

Patients going home are offered a care coordination visit with

Home Care in the first 24-48 hours after discharge. The home

care does a certified content visit including medication

reconciliation and determines eligibility.

St. Luke’s partnered with the hospital’s home care agency

(VNA) and two long-term care facilities to standardize and

enhance the quality of the handoff communication process. A

new interagency transfer form is now used. Warm handover

with those patients with complex issues.

Provided education for home care and long-term and skilled

care RNs and CNAs on HF, MI and Pneumonia and continuity

processes.


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Acute Inpatients Discharged and Readmitted within 30 Days

Initial Principal Diagnosis

2010 2011 2012 2013

486 Pneumonia, organism unspecified 48 51 57 58

38.9 Unspecified septicemia 37 37 35 58

428.33 Acute on chronic diastolic heart failure 18 14 22 56

491.21 Obstructive chronic bronchitis with exacerbation 31 37 31 54

518.84 Acute and chronic respiratory failure 20 38 32 32

410.71 Acute myocardial infarction, subendocardial 36 29 17 30

300.02 Generalized anxiety disorder 1 0 27

428.23 Acute on chronic systolic heart failure 6 19 10 26

482.83 Pneumonia due to other gram-negative bacteria 26

584.9 Acute kidney failure, unspecified 22 22 33 25

414.01 Coronary atherosclerosis of native coronary artery 24 17 35 22

493.22 Chronic obstructive asthma with exacerbation 4 7 1 22

427.31 Atrial fibrillation 15 12 13 21

298.9 Unspecified psychosis 0 1 1 20

715.96 Osteoarthrosis, unspecified whether generalized or 31 35 33 19

518.81 Acute respiratory failure 31 24 22 16

578.9 Hemorrhage of gastrointestinal tract, unspecified 7 8 13 14

562.11 Diverticulitis of colon (without mention of hemorr 18 18 9 13

303 Acute alcoholic intoxication in alcoholism, unspec 6 4 3 13

300 Anxiety state, unspecified 13


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Acute Inpatients Discharged and Readmitted within 30 Days

Readmitted Principal Diagnosis


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302724211815129630-3-6

12

10

8

6

4

2

0

Number of Days Between Admissions

Fre

qu

en

cy

Mean 10.36

StDev 8.389

N 56

Normal

Histogram of Days Between Admissions (with Outlier removed)

363024181260-6

12

11

10

9

8

7

6

5

4

3

2

1

0

Days between

Fre

qu

en

cy

7 14 30 Mean 15.10

StDev 8.773

N 49

Histogram of Days between Initial Discharge Date and Readmission Date

Heart Failure as Initial Admission

• Incomplete medical management

• Wrong site of post- acute care

• Socio-economic factors

• Physician follow-up

• Med problems

• Patient compliance with regime

• Disease trajectory


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HCAHPS RESULTS

DISCHARGE INFORMATION (% YES)

76

78

80

82

84

86

88

90

2009 2010 2011 2012 3Q 2012 -

2Q 2013

Pe

rce

nt

Ye

s

St. Luke's

State

National

Composite Score

• Q19 – During this hospital stay, did doctors, nurses or other hospital staff talk to you about whether you would

have the help you needed when you left the hospital?

• Q20 – During this hospital stay, did you get information in writing about what symptoms or health problems to

look out for after you left the hospital?

Prepared at the request of the Center for Medicare and Medicaid Innovation (CMMI)

http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pdf

http://www.mitre.org/work/health/news/bundled_payments/St_Lukes_Case_Study.pdf


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CRITICAL CAPABILITIES FOR CARE

REDESIGN INCLUDE:

Cross-continuum participation and

alignment

The development and use of standardized

tools and compatible information

infrastructure

Horizontal leaderships and executive

sponsorship and engaged physicians

Effective external and internal learning

45

LESSONS LEARNED

Importance of engaged executive leaders and physicians.

Patients and families help transform care in profound

ways.

The patient and family home environment must be

understood.

Involving front-line staff in the changes helps them

understand why they are important and grows

ownership by engaging them in redesign.

The power of relationship building and collaboration of

the cross-continuum team builds new ideas to work and

removes many of the “silos’ in the care.


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LESSONS LEARNED (CONT)

The role of Information Technology in the process

should be addressed simultaneously with the work.

Ongoing monitoring of Process and Outcome

Measures is important to hardwiring best practices.

Using patient stories unleashes energy and

participation that becomes evident in process and

outcome results.

QUESTIONS:

Peg Bradke RN, MA

Vice President, Post Acute Care Services

UnityPoint Health St. Luke’s

Cedar Rapids, IA

[email protected]

mailto:[email protected]

Documents

Heart Failure Disease Specific Certification –The Joint